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Prosthodontic Treatment Using Vital and Non Vital Submerged Roots-Two
Case Reports
Article in Journal of Clinical and Diagnostic Research · October 2013
DOI: 10.7860/JCDR/2013/6192.3537 · Source: PubMed
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DOI: 10.7860/JCDR/2013/6192.3435
Case Report
Prosthodontic Treatment Using Vital and Non
Dentistry Section
Vital Submerged Roots-Two Case Reports
Y. Ravi Shankar1, K. Srinivas2, HemChand Surapaneni3, S.V. Sudhakar Reddy4
ABSTRACT
Residual ridge resorption has been considered as an inevitable consequence after extraction of the teeth. There is a gradual loss of the
alveolar bone due to the pattern of bone remodeling. In spite of the availability of newer treatment modalities like endodontic restoration
and periodontic procedures for preservation of the remaining teeth they are not feasible for the patients in severe stages where restoration
might not be possible. The only reliable method of preserving the remaining bone is by maintaining the functional health of the teeth. Over
the years, many studies showed that roots which are fractured and left behind during extractions are retained into the alveolar bone with no
evidence of pathosis. Over denture as a treatment option was developed in an effort to preserve the remaining alveolar bone by retaining the
natural teeth or roots. In over denture treatment, the teeth selected as abutments are prone to caries and periodontal disease over a period
of time, hence evolved the vital or non vital root submergence concept. After a thorough radiographic and clinical examination, few teeth
without pathosis are retained that eventually are surgically submerged in the alveolar ridge. After healing, the over denture with reaining vital
or non vital teeth preserve the integrity of the bone, making the treatment an effective and successfull preventive prosthodontic treatment.
Key words: Alveolar resorption, Vital root, Non vital root, Sub mucosal retained roots, Over denture
Case report 1 were smoothened using a round bur and straight hand piece under
copious irrigation ensuring well rounded and smooth edges to the
Vital submerged root
hard tissue. Using a bone file, the interdental bone is smoothened.
A 46-year-old male patient reported to the department of
The flap is then approximated to evaluate for complete closure.
Prosthodontics for replacement of the missing teeth [Table/Fig-1].
In order to select the patient for root submergence treatment The flap was sutured and primary closure was obtained [Table/
medical history, dental history and history of habits was noted, Fig-4]. Patient was recalled after 7 days for suture removal. After
clinical examination, both intra oral and extra oral was done. For satisfactory healing an assessment of the intra arch space available
thorough examination OPG was advised [Table/Fig-2]. It was seen was recorded [Table/Fig-5]. The Interarch space was 18mm for
that there were multiple decayed teeth which cannot be restored this patient, which was sufficient for fabrication of a complete over
and many teeth were missing. Teeth 11,21,22,31 were extracted denture prosthesis supported by the underlying vital submerged
due to caries. With the remaining teeth that cannot be used roots. The over denture was fabricated in the conventional
as abutments for fixed prosthetic treatment, it was decided that method by making the preliminary impressions followed by border
root submergence could be the choice of treatment. The patient molding using a special tray with full spacer such that relief was
was informed about root submergence method of treatment, its given to the entire alveolar ridge with submerged roots. Light body
advantages and disadvantages. With the patients consent vital root polyvinlysiloxane was used for the wash impression so that accurate
submergence treatment was selected. details were recorded. Jaw relations were recorded followed by face
bow transfer using Hanau spring bow. Gothic arch tracing followed
Further evaluation was done after a healing period of one month.
by centric and protrusive records were obtained for programming
In the vital submergence technique, as the vitality of the root
the Hanau wide vue Arcon 183-2 articulator, for balanced occlusion.
has to be maintained, the teeth indicated for submergence were
Teeth arrangement was done in the neutral zone so that the forces
treated as atraumatically as possible. The vital root submergence
laid by the denture are well distributed on all the remaining hard
procedure was carried by reflecting the full thickness flap.
tissues such that further resorption of the residual ridge is reduced
The coronal part of the teeth selected for vital submergence
and clinical exposure of the retained roots is prevented. During Try-
(13,14,23,33,34,35,41,42,43,44) was reduced to 2mm below
in, proper occlusion was ensured and the fabricated denture was
the alveolar crest using a chisel and a mallet slowly such that the
lab remounted. All the occlusal corrections were done and after
vitality of the tooth is not effected [Table/Fig-3]. Once the tooth
ensuring proper occlusion, denture was delivered to the patient.
was sectioned 2mm below the alveolar crest, the irregular / sharp
Post-insertion instructions were given to the patient with emphasis
surface of the sectioned teeth and surrounding bony irregularities
[Table/Fig-1]: Pre-operative clinical photograph
[Table/Fig-2]: Pre-operative panoramic view
[Table/Fig-3]: Surgical Procedures for vital Submergence of roots
Journal of Clinical and Diagnostic Research, 2013. 1
Y. Ravi Shankar et al., Prosthodontic Treatment Using Vital and Non Vital Submerged Teeth: Two Case Reports [Link]
on maintenance of the denture. Patient was recalled after 6 months about the non-vital root submergence method of treatment, its
and OPG was taken. Radiographic examination revealed complete advantages and disadvantages. With the patients informed consent,
tissue coverage [Table/Fig-6]. Most of the retained vital roots While presenting the case to patient it was decided that few teeth
appeared normal. will be (13,16,17,26,27) extracted followed by root canal treatment
After a period of 1 year the patient was reevaluated [Table/Fig-7]. for all the remaining (14,15,23,24,25,32,33,34,43,44) teeth.
Radiograph revealed periapical pathology in 35,43 [Table/Fig-8] After the extraction and endodontic treatment of the indicated teeth
with clinical exposure of the submerged roots, Apart from those two was complete, patient was called for a review after one month. An
teeth all the remaining teeth were in sound health. The two teeth OPG was then taken to evaluate the condition of the remaining
were extracted and further evaluation of the patient was done after 1 teeth. The radiograph did not show any pathology and the remaining
month. Radiographs did not show any pathology, the alveolar bone teeth which were endodontically treated were in sound periodontal
was well formed and the healing was satisfactory. Patient did not health.
complain of ill fitting prosthesis even after extraction of the infected The non-vital root submergence was done by reflecting the
teeth. Phonetics and esthetics were evaluated and patient reported periosteal flap [Table/Fig-11], using a straight fissure carbide bur and
complete satisfaction. a hand piece under copious irrigation; the teeth were horizontally
sectioned till the crest of the ridge. Later using a round bur the teeth
Case report 2 were sectioned 2 mm below the crest of the alveolar ridge. The
Non vital submerged roots Guttapercha was burnished with a ball burnisher and remnants of
A 56-year-old female patient reported to the department of the tooth and gutta-percha were washed with saline. The uneven
Prosthodontics complaining of ill fitting upper and lower anterior surfaces of the interdental bone were smoothened using a bone
fixed prosthesis. The ill fitting prosthesis was removed [Table/Fig-9] file. Smooth and rounded surfaces were ensured. Later the flap
and OPG was advised; Medical history, dental history and history was approximated to ensure close proximity and the flap was
of habits was noted; clinical examination, both intra-oral and extra- sutured with tight closure. After 7 days the sutures were removed
oral was done. Examination of the radiograph revealed several and healing was evaluated. After satisfactory healing period of one
missing teeth (11,21,31,35,36,37,41,42,45,46,47) [Table/Fig-10] month, the intra arch space was recorded as 17 mm. Non vital
and inadequate bone support for maxillary posterior teeth. Patient submerged root supported complete over denture was fabricated
did not report of any medical history like diabetes or hypertension. in the conventional method starting with preliminary impressions,
As there was minimal crown portion of the tooth, which cannot be border molding and final impression, jaw relations, face bow
taken as abutment for fixed prosthesis, it was decided to retain the transfer, gothic arch tracing, centric and protrusive records to obtain
roots which were not infected hence non-vital root submergence a balanced occlusion. Try in was done where teeth were arranged
treatment was planned for the patient. The patient was informed in neutral zone so that the forces acting on the alveolar bone are
[Table/Fig-4]: Sutures Placed Post Surgically
[Table/Fig-5]: After Healing
[Table/Fig-6]: Six months post operative
[Table/Fig-7]: Panoramic view one year post operative
[Table/Fig-8]: One year post operative showing exposure
[Table/Fig-9]: Pre operative clinical presentation
[Table/Fig-10]: Pre operative panoramic view
[Table/Fig-11]: Surgical procedure for non vital Submergence of root
[Table/Fig-12]: Clinical presentation after healing
2 Journal of Clinical and Diagnostic Research, 2013.
[Link] Y. Ravi Shankar et al., Prosthodontic Treatment Using Vital and Non Vital Submerged Teeth: Two Case Reports
well distributed. The fabricated denture was delivered to the patient of intentional root submersion was by Bjorn in 1961 [9]. In 1970,
[Table/Fig-12]. Patient was educated about the maintenance and Howell reported a clinical study of submerged endodontically
post insertion care. After 3 months the patient was reevaluated and treated roots, some of which had been under observation for more
OPG was examined which did not reveal any periapical pathology than 10 years [10]. In 1973, Herd reported on 228 retained roots
[Table/Fig-13]. The patient was called for further evaluation after 1 from 171 patients [11]. He found that 163 of these roots had vital
year, an OPG was taken and it revealed no periapical pathology. The pulp tissue with no inflammation. Howell’s purpose was an attempt
crestal bone did not show any changes and there was no clinical to preserve alveolar bone. He claimed there was no apparent loss
exposure of the submerged roots [Table/Fig-14]. The patient was of bone in this long-term study and appears to be the first to utilize
satisfied with the over dentures. this technique for bone preservation under complete dentures. In
1973, Sander discussed the advantages of root retention for the
maintenance of alveolar bone. He cited the main disadvantage of
root submersion was the reduction in height of the vestibule [12].
In 1977 Cook et al., Performed a study similar to Bjorn’s 1965
study, except that the submerged teeth were vital. Pulpal tissues
associated with submerged roots appeared vital without significant
degeneration or inflammation. In 1978 Welker and associates
reported on 12 roots submerged in six patients. Eight were vital and
[Table/Fig-13]: Panoramic view after three months
four nonvital. Dentures had been worn over the roots for periods
up to 51 months [13]. All patients had been termed clinically
successful.
Atwood observed that the reduction of residual ridges needs to
be recognized as a major unsolved oral disease causing physical,
psychological and economical problems to many people. Both
objective and subjective findings clearly indicate the significant
benefits of the tooth retention since the extraction of few remaining
[Table/Fig-14]: Panoramic view after one year teeth is a serious decision [14]. Alveolar bone maintenance depends
on the presence of healthy roots and periodontal ligament which
transmit functional forces to the surrounding bone [15]. Denture
Discussion pressure on a residual ridge also results in bone resorption. The
Preserving the remaining bone can be achieved by maintaining technique of tooth root retention under complete dentures appears
the functional health of the teeth [1]. In over denture treatment, to militate against such a force application. The evaluation of
the abutment teeth are prone to caries and periodontal disease individual teeth for the presence or absence of pulpal involvement is
hence evolved the vital or non vital root submergence concept [2]. essential in the success of root submergence.
After a thorough radiographic and clinical examination, teeth are Proper diagnosis and endodontic treatment of submucosally
submerged in the alveolar ridge making it a preventive Prosthodontic retained roots lead to an excellent tissue acceptance and ridge
treatment [3]. The vital and non vital root submergence treatment is preservation. Three-month follow-up revealed excellent healing of
of importance in the aged, the handicapped and those with little or soft tissues. The oral tissues appeared normal in color and texture,
poor oral health maintenance [4]. The use of retained roots in over and the denture remained stable and retentive. The patient reported
denture reduces loss of alveolar bone and increases stability of the favorable denture experience [16]. Clinical examination revealed
over denture [5]. There are many advantages of this treatment like; no further reduction of the residual ridge in the region of retained
Preservation of the alveolar bone which enhances the retention of roots. One factor of major concern in this mode of treatment was
dentures. Vertical dimension of occlusion is maintained. The Average that there was decreased vestibular depth and also the intra arch
tactile perception to load for denture wearers was 10 times that of space was limited as the teeth were preserved [17]. As the retained
natural teeth. This treatment is Advantageous than over dentures roots preserved, undercuts were formed which make the path of
with attachments, as presence of attachments decreases the intra insertion and removal of the prosthesis difficult for the patient [18].
arch space making teeth arrangement difficult. In this method, The underlying teeth also increased the fullness of the lip in the facial
there is no criterion for preservation of teeth unlike conventional surface giving the lips a stretched appearance; in order to avoid this
over dentures where the configuration or location of the teeth has denture has to be relived in these areas at times soft liners were also
to be considered. Hence, any number of teeth can be preserved. used for the ease of removal and placement of the prosthesis.
It is comparatively inexpensive and maintenance procedure like
application of fluoride on the remaining natural teeth is not required Conclusion
as in conventional over denture treatment [6]. Mucosal coverage of roots as a means of preserving the residual
The vital and non vital root submergence treatment also has a few alveolar ridge is a sound clinical method for those patients where the
disadvantages like development of periapical pathology mostly in entire tooth or teeth cannot be preserved. When a comparison was
case of vital retained roots; this is a surgical procedure which at done between the vital and non-vital submerged root procedure,
times may not be advised depending on the systemic health of the vital root retention had more problems like periapical pathology
patient. of the root and pain sensation by the patient, hence the non vital
Clinical exposure of the submerged roots is also noticed in few root submergence method was an advisable option compared
cases; future extraction of the retained roots may cause instability to the vital root submergence. Both the treatment methods have
of the denture. Patient may have a stretched appearance of the lips certain drawbacks like poor esthetics of the prosthesis as it gives a
due to the preservation of the bone over which the denture flange stretched appearance of the lips. Hence, by this method of treatment
lies. There is also possible loss of vestibular depth due to surgery. the phonetics and the functionality of the patient were well preserved
with a little compromised esthetics. The undisturbed root attached
In 1959, Simpson examined a number of retained roots in humans
to the alveolar bone by the periodontal ligament is the “perfect”
and suggested that root fragments, which were originally unaffected,
implant, and by this method of treatment, many teeth as possible
could be safely left in position [7,8]. Preserving the teeth or the roots
preserves the periodontal ligament [9]. The first published report can be preserved in turn preserving the alveolar bone integrity.
Journal of Clinical and Diagnostic Research, 2013. 3
Y. Ravi Shankar et al., Prosthodontic Treatment Using Vital and Non Vital Submerged Teeth: Two Case Reports [Link]
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PARTICULARS OF CONTRIBUTORS:
1. Professor, Head of the Department of Prosthodontics, GITAM Dental College & Hospital, Visakhapatnam, India.
2. Reader, Department of Prosthodontics, GITAM Dental College & Hospital, Visakhapatnam, India.
3. Reader, Department of Prosthodontics, Dr. Sudha & Nageswarrao Siddhartha Institute of Dental Sciences, Vijayawada, India.
4. Postgraduate, Department of Prosthodontics, GITAM Dental College & Hospital, Visakhapatnam, India.
NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Y. Ravi Shankar, Date of Submission: Apr 29, 2013
Plot no.23, Door number: 7-5-148, Ocean view layout, Pandurangapuram, Visakhapatnam-530003, India. Date of Peer Review: Aug 09, 2013
Phone: 09885307066, E-mail: raviys124@[Link]
Date of Acceptance: Sep 03, 2013
Financial OR OTHER COMPETING INTERESTS: None. Date of Online Ahead of Print: Sep 18, 2013
4 Journal of Clinical and Diagnostic Research, 2013.
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